1 $600 is contributed annually to the HSA by Emory when Employee+Spouse, Employee+Children or Family level coverage is elected.

2 An annual maximum of $750 in incentives can be earned (for Single level coverage) or $900 (for Employee+Spouse or Family level coverage).

3 Amounts applied to deductible and out-of-pocket maximums are limited to the Reasonable and Customary charges.

4 Family deductible applies in the HSA plan when Employee+Spouse, Employee+Children or Family level coverage is elected.

5 Out-of-Pocket maximum includes co-pays.

6 Includes services of an internist, general physician, family practitioner, dermatologist or allergist.

7 Routine Preventive Care services ONLY are covered at 100% under the plan at the Tier 1 and Tier 2 Network levels. Diagnostic services are subject to the deductible and co-insurance.

8 Co-pay waived if admitted.

Disclaimer

Every attempt has been made to ensure the chart and information above accurately reflects the details of the plan. Should there be any errors, the terms and conditions of the Summary Plan Description (SPD) prevail.